Preserved splenic function after angioembolisation of high grade injury

Transarterial embolization to treat hemodynamically unstable trauma patients with splenic injuries: A retrospective multicenter observational study

PURPOSE

We described clinical outcomes for patients with blunt splenic injuries treated with transarterial embolization (TAE) based on their hemodynamic status.

MATERIALS AND METHODS

This is a retrospective two-center study of adult patients with splenic injuries who underwent emergency TAE between January 2011 and December 2022. Patients were divided into two groups; hemodynamically unstable (HDU) and hemodynamically stable (HDS) patients. HDU patients were defined as transient- or non-responders to fluid resuscitation and HDS as responders. When immediate laparotomy was not possible for HDU patients, angiography and embolization were performed. The primary outcome was the survival discharge rate. Rebleeding and splenectomy rate was also investigated.

RESULTS

Of 38 patients underwent emergency TAE for splenic trauma, 17 were HDU patients and 21 were HDS patients. The survival discharge rate was 88.2 % (15/17) in the HDU- and 100 % in HDS patients (p = 0.193). Rebleeding rate was 23.5 % (4/17) in HDU- and 5.0 % (1/21) in HDS patients (p = 0.15). Splenectomy was required for one HDU patient (5.9 %) for rebleeding.

CONCLUSION

The survival discharge rate of TAE for splenic trauma in HDU patients was acceptable with a low rate of splenectomy. Further comparative studies of TAE versus operative management in HDU patients are needed to prove the usefulness of TAE.

Prevention and treatment of infection in patients with an absent or hypofunctional spleen: A British Society for Haematology guideline

Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were published by the British Committee for Standards in Haematology in 1996 and updated in 2002 and 2011. With advances in vaccinations and changes in patterns of infection, the guidelines required updating. Key aspects included in this guideline are the identification of patients at risk of infection, patient education and information and immunisation schedules. This guideline does not address the non-infective complications of splenectomy or functional hyposplenism (FH). This replaces previous guidelines and significantly revises the recommendations related to immunisation. Patients at risk include those who have undergone surgical removal of the spleen, including partial splenectomy and splenic embolisation, and those with medical conditions that predispose to FH. Immunisations should include those against Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and influenza. Haemophilus influenzae type b (Hib) is part of the infant immunisation schedule and is no longer required for older hyposplenic patients. Treatment of suspected or proven infections should be based on local protocols and consider relevant anti-microbial resistance patterns. The education of patients and their medical practitioners is essential, particularly in relation to the risk of serious infection and its prevention. Further research is required to establish the effectiveness of vaccinations in hyposplenic patients; infective episodes should be regularly audited. There is no single group ideally placed to conduct audits into complications arising from hyposplenism, highlighting a need for a national registry, as has proved very successful in Australia or alternatively, the establishment of appropriate multidisciplinary networks.

Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Angioembolization is an important adjunct in the non-operative management of adult trauma patients with splenic injury. Multiple studies have shown that angioembolization may increase the non-operative splenic salvage rate for patients with high-grade splenic injuries. We performed a systematic review and developed evidence-based recommendations regarding the need for post-splenectomy vaccinations after splenic embolization in trauma patients.

METHODS

A systematic review and meta-analysis of currently available evidence were performed utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Nine studies were identified and analyzed. A total of 240 embolization patients were compared to 443 control patients who neither underwent splenectomy nor were embolized. There was no statistical difference between the splenic immune function of embolized and control patients. In addition, a total of 3974 splenectomy patients was compared with 686 embolization patients. Embolization patients had fewer infectious complications and a greater degree of preserved splenic immune function.

CONCLUSION

In adult trauma patients who have undergone splenic angioembolization, we conditionally recommend against routine post-splenectomy vaccinations.

STUDY TYPE

systematic review/meta-analysis Level of evidence: level III.

Application of Alginate-Based Hydrogels in Hemostasis

Hemorrhage, as a common trauma injury and clinical postoperative complication, may cause serious damage to the body, especially for patients with huge blood loss and coagulation dysfunction. Timely and effective hemostasis and avoidance of bleeding are of great significance for reducing body damage and improving the survival rate and quality of life of patients. Alginate is considered to be an excellent hemostatic polymer-based biomaterial due to its excellent biocompatibility, biodegradability, non-toxicity, non-immunogenicity, easy gelation and easy availability. In recent years, alginate hydrogels have been more and more widely used in the medical field, and a series of hemostatic related products have been developed such as medical dressings, hemostatic needles, transcatheter interventional embolization preparations, microneedles, injectable hydrogels, and hemostatic powders. The development and application prospects are extremely broad. This manuscript reviews the structure, properties and history of alginate, as well as the research progress of alginate hydrogels in clinical applications related to hemostasis. This review also discusses the current limitations and possible future development prospects of alginate hydrogels in hemostatic applications.

Splenic Artery Angioembolization is Associated with Increased Venous Thromboembolism

BACKGROUND

Angioembolization has become an increasingly utilized adjunct for splenic preservation after trauma. Embolization of the splenic artery may produce a transient systemic hypercoagulable state. This study was designed to determine the risk of venous thromboembolism (VTE) in blunt trauma patients managed nonoperatively with splenic angioembolization, relative to those managed without.

METHOD

Retrospective review of the American College of Surgeons Trauma Quality Improvement Performance (TQIP) Database from 2013 to 2016. Adult (>16 years) patients with isolated, severe (Grades III-V) blunt splenic injuries managed nonoperatively who received pharmacological VTE prophylaxis formed the study population. Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), or any VTE.

RESULTS

A total of 2643 patients met inclusion criteria (69.1% Grade III, 26.5% Grade IV, 4.5% Grade V). The incidence of DVT was 4.5% in patients who underwent angioembolization, compared to 1.4% in patients who did not (p<0.001). Multivariable analysis showed that angioembolization was an independent risk factor for both DVT (OR 2.65, p = 0.006) and any VTE (OR 2.04, p = 0.01). Analysis according to splenic injury Grades showed that angioembolization remained an independent risk factor for DVT (p = 0.004) in the Grade IV-V injury group, and for VTE (p<0.01) in the Grade III injury group. Initiation of pharmacological VTE prophylaxis 48 h after admission was associated with increased VTE rates in comparison to early initiation (OR 1.75, p = 0.02) CONCLUSIONS: Splenic artery angioembolization may be an independent risk factor for VTE events in isolated, severe blunt splenic trauma managed nonoperatively. Early prophylaxis with LMWH after intervention should be strongly considered.

Trends in hematologic markers after blunt splenic trauma: Risk factor or Epiphenomenon?

BACKGROUND

Most blunt splenic injuries (BSI) are treated with nonoperative management (NOM) or embolization (EMBO). Little is known about the hematologic changes associated with these treatments. We aim to assess the temporal changes of hematologic markers in trauma patients who undergo splenectomy (SPL), packing and splenorrhaphy (P/S), EMBO, or NOM. We hypothesize that differences in trends of hematologic markers exist in patients undergoing EMBO or SPL, compared to NOM.

METHODS

An 8-year review of adult patients with BSI and underwent SPL, EMBO, P/S, or NOM. White blood cell count (WBC), hematocrit (HCT) and platelet count (PLT) at presentation to 14 days post-admission were analyzed; post-procedural complications were reviewed. Temporal trends were compared using linear mixed-effects models.

RESULTS

478 patients sustained BSI, 298 (62.3%) underwent NOM, 100 (29.2%) SPL, 42 (8.8%) EMBO, and 38 (8.0%) P/S. After adjustment for age, ISS and splenic injury grade, SPL patients had a significantly higher upward trend compared to other management strategies (p < 0.05). Infection further increased this trend. Starting on day 6, SPL patients with infections had significantly higher WBC than those without infection. SPL and P/S were more likely than NOM to develop infections after adjustment for confounders (HR = 3.64; 95%CI: 1.79-7.39 and HR = 2.59; 95%CI: 1.21-5.55, respectively). Day 6 WBC>16,000 cells/ml post-SPL had a positive predictive value (PPV) of 65.2% and negative predictive value (NPV) of 76.9% for infections. Among P/S, Day 6 WBC >10,200 cells/ml had a PPV = 50% and NPV = 86.7% for infections.

CONCLUSIONS

We observed distinct patterns of hematologic markers following BSI managed with SPL, EMBO, P/S, and NOM. Day 6 WBC increases after SPL or P/S should raise suspicion of infections and trigger a diagnostic investigation.

Splenic artery embolisation in trauma: A five-year single-centre experience at a UK major trauma centre

Introduction

Since the introduction of major trauma centres and regional trauma networks in 2012, management of splenic injury has shifted, with non-operative management now favoured. For those requiring intervention, splenic artery embolisation is well established as a first-line treatment in all but the most severely injured. Follow-up is variable, with few guidelines, highlighting the paucity of data addressing the need for further imaging and antimicrobial prophylaxis. This review was undertaken to assess practice and outcomes at our centre in the context of the contemporary literature.

Methods

This retrospective study captured splenic embolisations over five years (January 2012–December 2016). CRIS interventional radiology codes were used to retrieve embolisation cases and Trauma Audit and Research Network and hospital event statistics data were used to identify all cases of traumatic splenic injury and to identify splenectomy and non-operative management patients. Outcomes were compared with available standards from different sources.

Results

Over the study period 176 splenic injuries were identified, of which 122 underwent non-operative management, 28 were laparotomy first, and 26 undergoing embolisation with an increased trend to an ‘embolisation-first’ approach over this time. In the embolisation group, the age range was 16–79 yr (mean 41), 18 were male and the median time to intervention was 2 h 9 min (range 1.1–171 h), with eight following failed non-operative management. The proportion of proximal versus selective embolisation versus both was 10:14:1 and the predominant mechanism was coiling. One patient was not embolised due to absence of contrast extravasation on initial angiogram and two proceeded to splenectomy due to failure of splenic artery embolisation. There were complications in six patients: five ongoing left upper quadrant pain, one infected haematoma requiring drainage, two chest infections with pleural effusions, one of which required drainage. There were two deaths from other injuries. Fifteen of the 25 patients who underwent splenic artery embolisation had follow-up imaging, seven did not and three were excluded due to splenectomy and/or death; five patients were vaccinated according to the hospital splenectomy protocol, and six received prophylactic antibiotics.

Conclusion

Our data show that non-operative management is the mainstay of treatment for the majority of splenic injury patients. Serious complications are not common but variation does exist in follow-up. The changing management trends are in line with national data. These findings will help to further implement and develop local protocols but more work is required to address splenic function after embolisation and the requirement for antimicrobial prophylaxis.

Patterns and outcomes of patients with abdominal trauma on operative management from northern Tanzania: a prospective single centre observational study

BACKGROUND

The abdomen is one of the most commonly injured regions in trauma patients. Abdominal injury surgeries are common in Tanzania and in many parts of the world. This study aimed to determine the relationships among the causes, characteristics, patterns and outcomes of abdominal injury patients undergoing operations at Kilimanjaro Christian Medical Centre.

METHODS

A prospective observational study was performed over a period of 1 year from August 2016 to August 2017. A case was defined as a trauma patient with abdominal injuries admitted to the general surgery department and undergoing an operation. We assessed injury types, patterns, aetiologies and outcomes within 30 days. The outcomes were post-operative complications and mortality. Multivariate logistic regression was used to explore the association between factors associated with morbidity and mortality.

RESULTS

Out of 136 patients, 115 (84.6%) were male, with a male-to-female ratio of 5.5:1. The most affected patients were in the age range of 21-40 years old, which accounted for 67 patients (49.3%), with a median age (IQR) of 31.5 (21.3-44.8) years. A majority (99 patients; 72.8%) had blunt abdominal injury, with a blunt-to-penetrating ratio of 2.7:1. The most common cause of injury was road traffic accidents (RTAs; 73 patients; 53.7%). Commonly injured organs in blunt and penetrating injuries were, respectively, the spleen (33 patients; 91.7%) and small bowel (12 patients; 46.1%). Most patients (89; 65.4%) had associated extra-abdominal injuries. Post-operative complications were observed in 57 patients (41.9%), and the mortality rate was 18 patients (13.2%). In the univariate analysis, the following were significantly associated with mortality: associated extra-abdominal injury (odds ratio (OR): 4.9; P-value< 0.039); head injury (OR: 4.4; P-value < 0.005); pelvic injury (OR: 3.9; P-value< 0.043); length of hospital stay (LOS) ≥ 7 days (OR: 4.2; P-value < 0.022); severe injury on the New Injury Severity Score (NISS) (OR: 21.7; P-value < 0.003); time > 6 h from injury to admission (OR: 4.4; P-value < 0.025); systolic BP < 90 (OR: 3.5; P-value < 0.015); and anaemia (OR: 4.7; P-value< 0.006). After adjustment, the following significantly predicted mortality: severe injury on the NISS (17 patients; 25.8%; adjusted odds ratio (aOR): 15.5, 95% CI: 1.5-160, P-value < 0.02) and time > 6 h from injury to admission (15 patients; 19.2%; aOR: 4.3, 95% CI: 1.0-18.9, P-value < 0.05).

CONCLUSION

Blunt abdominal injury was common and mostly associated with RTAs. Associated extra-abdominal injury, injury to the head or pelvis, LOS ≥ 7 days, systolic BP < 90 and anaemia were associated with mortality. Severe injury on the NISS and time > 6 h from injury to admission significantly predicted mortality.

Long-Term Follow-Up After Non-operative Management of Blunt Splenic and Liver Injuries: A Questionnaire-Based Survey

BACKGROUND

Non-operative management (NOM) of blunt splenic or liver injuries (solid organ injury, SOI) has become the standard of care in hemodynamically stable patients. However, the incidence of long-term symptoms in these patients is currently not known. The aim of this study was to assess long-term symptoms in patients undergoing successful NOM (sNOM) for SOI.

METHODS

Long-term posttraumatic outcomes including chronic abdominal pain, irregular bowel movements, and recurrent infections were assessed using a specifically designed questionnaire and analyzed by univariable analysis.

RESULTS

Eighty out of 138 (58%) patients with SOI undergoing sNOM) responded to the questionnaire. Median (IQR) follow-up time was 48.8 (28) months. Twenty-seven (34%) patients complained of at least one of the following symptoms: 17 (53%) chronic abdominal pain, 13 (41%) irregular bowel movements, and 8 (25%) recurrent infections. One female patient reported secondary infertility. No significant association between the above-mentioned symptoms and the Injury Severity Score, amount of hemoperitoneum, or high-grade SOI was found. Patients with chronic pain were significantly younger than asymptomatic patients (32.1 ± 14.5 vs. 48.3 ± 19.4 years, p = 0.002). Irregular bowel movements were significantly more frequent in patients with severe pelvic fractures (15.4 vs. 0.0%, p = 0.025). A trend toward a higher frequency of recurrent infections was found in patients with splenic injuries (15.9 vs. 2.8%, p = 0.067).

CONCLUSION

A third of patients with blunt SOI undergoing sNOM reported long-term abdominal symptoms. Younger age was associated with chronic abdominal symptoms. More studies are warranted to investigate long-term outcomes immunologic sequelae in patients after sNOM for SOI.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Partial Splenic Artery Embolization to Treat Hypersplenism Secondary to Hepatic Cirrhosis: A Meta-Analysis

This meta-analysis aimed to explore the effectiveness of partial spleen arterial embolization (PSAE) in the treatment of hypersplenism secondary to hepatic cirrhosis. PubMed, Embase, Cochrane Library, Wan Fang, CNKI, Vip, and CBM databases were searched for randomized controlled trials, cohort studies, and case–control studies that compared PSAE with splenectomy in the treatment of hypersplenism secondary to hepatic cirrhosis from their inception to July 25, 2015. Statistical analysis was conducted in Cochrane Network RevMan v5.3. Primary outcomes included the pre- and postoperative platelet and leukocyte counts and hemoglobin levels. Secondary outcomes were operative time, intraoperative volume of bleeding, and length of hospital stay. Mean and standard deviation were obtained from each study and then pooled using fixed- or random-effects models to calculate the mean difference. Ten original studies investigating 737 patients were included. Both the PSAE group and the splenectomy group yielded higher postoperative platelet and leukocyte counts and hemoglobin levels than the preoperative. The difference of platelet and leukocyte counts and hemoglobin levels between postoperative and preoperative levels in the PSAE group was smaller than that in the splenectomy group. Besides, compared with the splenectomy group, the PSAE group exhibited shorter operative time, less intraoperative bleeding, and shorter length of stay. PSAE is a mini-invasive therapy, which can be applied to treat hypersplenism secondary to hepatic cirrhosis effectively, particularly for patients with a poor overall condition. However, further high-quality studies should be conducted because this meta-analysis is limited by the quality of studies and the large statistical heterogeneity.

Evidence-Based Management and Controversies in Blunt Splenic Trauma

PURPOSE OF REVIEW

The study aims to describe the evidence-based management and controversies in blunt splenic trauma.

RECENT FINDINGS

A shift from operative management to non-operative management (NOM) has occurred over the past decades where NOM has now become the standard of care in haemodynamically stable patients with blunt splenic injury. Splenic artery embolisation (SAE) is generally believed to increase the success rate of NOM. Not all the available evidence is that optimistic about SAE however. A morbidity specifically related to SAE of up to 47% has been reported. Although high-grade splenic injury is a prognostic factor for failure of NOM, an American research group has published a study in which NOM is performed in over half of haemodynamically stable patients with grade IV or V splenic injury without leading to an increased morbidity (in terms of complications) or mortality. Another area of current investigation in the literature is the exact indication for SAE. Although the generally accepted indication is the presence of vascular injury, a topic of current investigation is whether there might be a role for pre-emptive embolisation in patients with high-grade splenic injury. On the other hand, evidence is also emerging that not all blushes require an intervention (small blushes <1 or 1.5 cm do not). Lastly, the available evidence shows that splenic function is preserved after embolisation, and therefore, the routine administration of vaccinations seems not to be necessary. There might be a difference between proximal and distal embolisations; however, with regard to splenic function, in favour of distal embolisation.

SUMMARY

Nowadays, NOM is the standard of care in haemodynamically stable patients with blunt splenic injury. The available evidence (although with a relatively small number of patients) shows that splenic function is preserved after NOM, a major advantage compared to splenectomy. SAE is used as an adjunct to observation in order to increase the success rate of NOM. Operative management should be applied in case of haemodynamic instability or if associated intra-abdominal injuries requiring surgical treatment are present. Patient selection (which patient can be safely treated non-operatively, does every blush needs to be embolised?, which patients might be better off with direct operative intervention given the patient and injury characteristics) is an ongoing subject of further research. Future studies should also focus on long-term outcomes of patients treated with embolisation (e.g. total number of lifetime infectious episodes requiring antibiotic treatment or hospital admission, quality of life).

The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis

BACKGROUND

Splenic artery embolization (SAE) has been an effective adjunct to the Non-operative management (NOM) for blunt splenic injury (BSI). However, the optimal embolization techniques are still inconclusive. To further understand the roles of different embolization locations and embolic materials in SAE, we conducted this system review and meta-analyses.

METHODS

Clinical studies related to SAE for adult patients were researched in electronic databases, included PubMed, Embase, ScienceDirect and Google Scholar Search (between October 1991 and March 2013), and relevant information was extracted. To eliminate the heterogeneity, a sensitivity analysis was conducted on two reduced study sets. Then, the pooled outcomes were compared and the quality assessments were performed using Newcastle-Ottawa Scale (NOS). The SAE success rate, incidences of life-threatening complications of different embolization techniques were compared by χ² test in 1st study set. Associations between different embolization techniques and clinical outcomes were evaluated by fixed-effects model in 2nd study set.

RESULTS

Twenty-three studies were included in 1st study set. And then, 13 of them were excluded, because lack of the necessary details of SAE. The remaining 10 studies comprised 2nd study set, and quality assessments were performed using NOS. In 1st set, the primary success rate is 90.1% and the incidence of life-threatening complications is 20.4%, though the cases which required surgical intervention are very few (6.4%). For different embolization locations, there was no obvious association between primary success rate and embolization location in both 1st and 2nd study sets (P > 0.05). But in 2nd study set, it indicated that proximal embolization reduced severe complications and complications needed surgical management. As for the embolic materials, the success rate between coil and gelfoam is not significant. However, coil is associated with a lower risk of life-threatening complications, as well as less complications requiring surgical management.

CONCLUSIONS

Different embolization techniques affect the clinical outcomes of SAE. The proximal embolization is the best option due to the less life-threatening complications. For commonly embolic material, coil is superior to gelfoam for fewer severe complications and less further surgery management.

Splenic artery embolization: technically feasible but not necessarily advantageous

Background

The spleen is the second most commonly injured organ in cases of abdominal trauma. Management of splenic injury depends on the clinical status of the patient and can include nonoperative management (NOM), splenic artery embolization (SAE), surgery (operative splenic salvage or splenectomy), or a combination of these treatments. In nonoperatively managed cases, SAE is sometimes used to control haemorrhage. However, the indications for SAE have not been clearly defined and, in some cases, the potential complications of the procedure may outweigh its benefits.

Review of the literature

Through review of the literature we address the question of when SAE is indicated in combination with NOM of splenic injury, and whether SAE may delay needed surgical treatment in some cases. This systematic review highlighted the use of imperfect and inconsistent scoring systems in the diagnosis of splenic injury, the lack of consensus regarding indications for SAE, and the potential for severe morbidities associated with this procedure. Based on current literature and evidence we provide a new, non-verified, decision algorithm.

Conclusions

NOM+ SAE involves potential risks and operative management may be preferable to SAE for certain patients. To clarify current literature, we propose a new algorithm for blunt abdominal trauma that should be validated prospectively. New evidence-based protocols should be developed to guide diagnosis and management of patients with splenic trauma.

Electronic supplementary material

The online version of this article (doi:10.1186/s13017-016-0100-7) contains supplementary material, which is available to authorized users.

Temporal changes in hematologic markers after splenectomy, splenic embolization, and observation for trauma

INTRODUCTION

The spleen is one of the most commonly injured abdominal solid organs during blunt trauma. Modern management of splenic trauma has evolved to include non-operative therapies, including observation and angioembolization to preclude splenectomy in most cases of blunt splenic injury. Despite the shift in management strategies, relatively little is known about the hematologic changes associated with these various modalities. The aim of this study was to determine if there are significant differences in hematologic characteristics over time based on the treatment modality employed following splenic trauma. We hypothesized that alterations seen in hematologic parameters would vary between observation (OBS), embolization (EMB), and splenectomy (SPL) in the setting of splenic injury.

METHODS

An institutional review board-approved, retrospective study of routine hematologic indices examined data between March 2000 and December 2014 at three academic trauma centers. A convenience sample of patients with splenic trauma and admission lengths of stay >96 h was selected for inclusion, resulting in a representative sample of each sub-group (OBS, EMB, and SPL). Basic demographics and injury severity data (ISS) were abstracted. Platelet count, red blood cell (RBC) count and RBC indices, and white blood cell (WBC) count with differential were analyzed between the time of admission and a maximum of 1080 h (45 days) post-injury. Comparisons between OBS, EMB, and SPL groups were then performed using non-parametric statistical testing, with statistical significance set at p < 0.05.

RESULTS

Data from 130 patients (40 SPL, 40 EMB, and 50 OBS) were analyzed. The median age was 40 years, with 67 % males. Median ISS was 21.5 (21 for SPL, 19 for EMB, and 22 for OBS, p = n/s) and median Glasgow Coma Scale (GCS) was 15. Median splenic injury grade varied by interventional modality (grade 4 for SPL, 3 for EMB, and 2 for OBS, p < 0.05). Inter-group comparisons demonstrated no significant differences in RBC counts. However, mean corpuscular volume (MCV) and RBC distribution width (RDW) were elevated in the SPL and EMB groups (p < 0.01). Similarly, EMB and SPL groups had higher platelet counts than the OBS group (p < 0.01). In aggregate, WBC counts were highest following SPL, followed by EMB and OBS (p < 0.01). Similar trends were noted in neutrophil and monocyte counts (p < 0.01), but not in lymphocyte counts (p = n/s).

CONCLUSION

This study describes important trends and patterns among fundamental hematologic parameters following traumatic splenic injuries managed with SPL, EMB, or OBS. As expected, observed WBC counts were highest following SPL, then EMB, and finally OBS. No differences were noted in RBC count between the three groups, but RDW was significantly greater following SPL compared to EMB and OBS. We also found that MCV was highest following OBS, when compared to EMB or SPL. Finally, our data indicate that platelet counts are similarly elevated for both SPL and EMB, when compared to the OBS group. These results provide an important foundation for further research in this still relatively unexplored area.

Splenic function after angioembolization for splenic trauma in children and adults: A systematic review

PURPOSE

Splenic artery embolization (SAE), proximal or distal, is becoming the standard of care for traumatic splenic injury. Theoretically the immunological function of the spleen may be preserved, but this has not yet been proven. A parameter for measuring the remaining splenic function must therefore be determined in order to decide whether or not vaccinations and/or antibiotic prophylaxis are necessary to prevent an overwhelming post-splenectomy infection (OPSI).

METHODS

A systematic review of the literature was performed July 2015 by searching the Embase and Medline databases. Articles were eligible if they described at least two trauma patients and the subject was splenic function. Description of procedure and/or success rate of SAE was not necessary for inclusion. Two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction.

RESULTS

Twelve studies were included, eleven with adult patients and one focusing on children. All studies used different parameters to assess splenic function. None of them reported a OPSI after splenic embolization. Eleven studies found a preserved splenic function after SAE, in both adults and children.

CONCLUSION

All but one studies on the long term effects of SAE indicate a preserved splenic function. However, there is still no single parameter or test available which can demonstrate that unequivocally.

Nonoperative management of splenic injury grade IV is safe using rigid protocol

OBJECTIVE

To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries.

METHODS

This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study.

RESULTS

ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days.

CONCLUSION

Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.

Antibody response to a T-cell-independent antigen is preserved after splenic artery embolization for trauma

Splenic artery embolization (SAE) is increasingly being used as a nonoperative management strategy for patients with blunt splenic injury following trauma. The aim of this study was to assess the splenic function of patients who were embolized. A clinical study was performed, with splenic function assessed by examining the antibody response to polysaccharide antigens (pneumococcal 23-valent polysaccharide vaccine), B-cell subsets, and the presence of Howell-Jolly bodies (HJB). The data were compared to those obtained from splenectomized patients and healthy controls (HC) who had been included in a previously conducted study. A total of 30 patients were studied: 5 who had proximal SAE, 7 who had distal SAE, 8 who had a splenectomy, and 10 HC. The median vaccine-specific antibody response of the SAE patients (fold increase, 3.97) did not differ significantly from that of the HC (5.29; P = 0.90); however, the median response of the splenectomized patients (2.30) did differ (P = 0.003). In 2 of the proximally embolized patients and none of the distally embolized patients, the ratio of the IgG antibody level postvaccination compared to that prevaccination was <2. There were no significant differences in the absolute numbers of lymphocytes or B-cell subsets between the SAE patients and the HC. HJB were not observed in the SAE patients. The splenic immune function of embolized patients was preserved, and therefore routine vaccination appears not to be indicated. Although the median antibody responses did not differ between the patients who underwent proximal SAE and those who underwent distal SAE, 2 of the 5 proximally embolized patients had insufficient responses to vaccination, whereas none of the distally embolized patients exhibited an insufficient response. Further research should be done to confirm this finding.

Emergency treatment of splenic injury in a novel mobile minimally invasive interventional shelter following disaster: a feasibility study

Background

There has been an increase in natural disasters in recent years, which leads to a great number of injuries and deaths. It still remains an unsolved problem to treat patients with vascular injury of solid organs effectively following natural disasters, but on-spot emergency interventional transcatheter arterial embolization (TAE) has been highly recommended to cure serious vascular injury of solid organs nowadays. Spleen is the most vulnerable abdominal organ, severe arterial hemorrhage of which can cause death if untreated timely. In this research, we aimed to study the possibility of performing emergency surgical intervention in mobile minimally invasive interventional shelter for splenic injury in the case of natural disasters.

Methods

First, the mobile minimally invasive interventional shelter was unfolded in the field, and then disinfection and preoperative preparation were performed immediately. Eight large animal models of splenic injury were created, and angiograms were performed using a digital subtraction angiography machine in the mobile minimally invasive interventional shelter, and then the hemostatic embolizations of injured splenic artery were performed following the established convention of rapid intervention therapy. The operating time was recorded, and the survival condition and postoperative complications were observed for two weeks.

Results and discussion

The average time of unfolding the shelter, and performing disinfection and preoperative preparation was 33 ± 7 min. The number of colonies in the sterilized shelter body was 86 ± 13 cfu/m³. The average TAE time was 31 ± 7 min. All the hemostatic embolizations of splenic injury were performed successfully in the mobile minimally invasive interventional shelter during the operation. A pseudoaneurysm was found in an animal model using angiography two weeks after the operation. The primary clinical success rate of embolization was 87.5%. The two-week survival rate in all animal models of splenic injury was 100%.

Conclusions

Our findings in the current study demonstrate that the mobile minimally invasive interventional shelter can be adapted to the field perfectly and complete emergency surgical intervention for splenic injury efficiently and safely. Therefore, on-spot emergency interventional TAE for vascular injury of solid organs (e.g. spleen) in mobile minimally invasive interventional shelter is available and effective.

Preserved function after angioembolisation of splenic injury in children and adolescents: a case control study

BACKGROUND

Non-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study.

METHODS

A total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell-Jolly bodies (H-J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen.

RESULTS

On average 4.6 years after SAE (range 1-8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H-J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls.

CONCLUSION

This case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.

Splenic artery embolisation in children and adolescents--an 8 year experience

BACKGROUND

Non-operative management (NOM) is the treatment of choice in blunt splenic injuries in the paediatric population, with reported success rates exceeding 90%. Splenic artery embolisation (SAE) was added to our institutional treatment protocol for splenic injury in 2002. We wanted to review indications for SAE and the clinical outcome of splenic injury management in children admitted between August 1, 2002 and July 31, 2010.

METHODS

Patients aged <17 years with splenic injury were identified in the institutional trauma and medical code registries. Patient charts and computed tomographic (CT) scans were reviewed.

RESULTS

Of the 72 children and adolescents with splenic injury included during the 8 year study period, 66 patients (92%) were treated non-operatively and six underwent operative management. Severe splenic injury (OIS grade 3-5) was diagnosed in 67 patients (93%). SAE was performed in 22 of the NOM patients. Indications for SAE included - bleeding (n=8), pseudoaneurysms (n=2), contrast extravasation (n=2), high OIS injury grade (n=8) and prophylactic due to specific disease (n=2). NOM was successful in all but one case (98%). For the patients aged ≤ 14 years, extravasation on initial CT scan correlated to delayed bleeding (p<0.001). Two SAE procedure specific complications were registered, but resolved without significant sequelae.

CONCLUSION

After SAE was added to the institutional treatment protocol, 22 of 66 NOM paediatric patients underwent SAE. NOM was successful in 98% and a 90% splenic preservation rate was achieved. Contrast extravasation correlated to delayed splenic bleeding in children ≤ 14 years.

Embolization for pediatric blunt splenic injury is an alternative to splenectomy when observation fails

BACKGROUND

Management of splenic injury has shifted from operative to nonoperative management in both children and adults with reports of high success rates. Benefits of splenic conservation include decreased hospital stay, blood transfusion, and mortality, as well as avoidance of infectious complications. Angiography with embolization is an innovative adjunct to nonoperative management and has resulted in increased splenic salvage in adults; however, data in the pediatric population are scant.

METHODS

A retrospective comparative study of a single-hospital trauma registry reviewed from 1999 to 2009. Patients 18 years and younger admitted with injury to the spleen were included. Children with penetrating injury were excluded. Children were divided into three categories by initial treatment: observation, embolization, or splenectomy. Data recorded include age, radiographic grade of injury, and Injury Severity Score (ISS). Groups were analyzed for success of initial treatment, requirement for transfusion of packed red blood cells, splenic salvage, and mortality.

RESULTS

Registry review identified 259 children with blunt splenic injury. Initial treatment was observation in 227, embolization in 15, and splenectomy in 17. In the observation group, 9 (4%) of 227 children failed initial treatment; 8 of these underwent embolization, while 1 unerwent splenectomy. In the embolization group, 1 (7%) of 15 failed initial treatment and underwent splenectomy. Blood transfusion was required by 38 (17%) of 227 in the observation group, 6 (40%) of 15 (p = 0.02) in the embolization group, and 15 (88%) of 17 (p < 0.01) in the splenectomy group. Overall splenic salvage rate was 237 (92%) of 259. Three children died in the observation group, and four children died in the splenectomy group. There was no death in the embolization group.

CONCLUSION

Splenic artery embolization for blunt trauma in children is associated with a higher blood transfusion rate compared with observation but offers a safe, intermediate alternative to splenectomy when observation fails.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Splenic artery embolization as an adjunctive procedure for portal hypertension

Splenic embolization is a technique that can be used alone or in conjunction with other treatments for the mitigation of portal hypertension and associated physiological effects of portal hypertension. This technique can be used safely when total embolization volume is ~50% and the procedural and periprocedural time periods are covered with antibiotics. In this patient population, partial splenic embolization can decrease the incidence of variceal bleeding, and protection can persist for at least a year. Additionally, liver function tests and serum cell counts can be expected to improve. Although not frequently used as primary therapy for patients with portal hypertension, splenic embolization can often be helpful as an alternative or adjunctive procedure.

Hyposplenism: comparison of different methods for determining splenic function

Asplenic patients are at risk for pneumococcal sepsis. Patients with hyposplenic function, such as associated with sickle cell disease (SCD), are also at risk. However, tests to assess splenic function are either unavailable or lacking standardization. The aim of this study was to compare different methods for determining splenic function. Eighteen patients with SCD (i.e., 10 heterozygous (SC) and 8 homozygous (SS) SCD patients), and eight splenectomized patients were compared to 10 controls. All subjects underwent spleen scintigraphy, after which functional splenic volumes (FSV) were calculated. FSV was compared to immunological function and B cell-subsets, as well as phagocytic function represented by the presence of Howell Jolly bodies (HJB) and percentages of pitted red cells (PIT). Heterozygous SCD (SC) patients had increased splenic volumes, but diminished FSV, homozygous SCD (SS) patients were asplenic. Splenectomized and SS patients had a strongly reduced phagocytic and immunological function. SC patients had reduced anti-polysaccharide responses without an increase in PIT. FSV correlated significantly with phagocytic and immunological function. HJB were indicative of splenic dysfunction, HJB absence was not indicative of normal functioning splenic tissue. Although visualizing HJB is methodologically advantageous to PIT, both are valid biomarkers of splenic dysfunction. The amount of non-switched memory B cells is strongly correlated to FSV.